NC General Statutes - Chapter 135 Article 3B 1

Transcription

1 Article 3B. State Health Plan for Teachers and State Employees. Part 1. General Provisions General definitions. As used in this Article unless the context clearly requires otherwise, the following definitions apply: (1) Benefit period. The period of time during which charges for covered services provided to a Plan member must be incurred in order to be eligible for payment by the Plan. (2) Chemical dependency. The pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. (2a) Claims Data Feed. An electronic file provided by a Claims Processor that contains all claims processing data elements for every claim processed by the Claims Processor for the Plan, including Claim Payment Data for each claim. (2b) Claim Payment Data. Data fields within a Claims Data Feed that reflect the provider and the amount the provider billed for services provided to a Plan member, the allowed amount applied to the claim by the Claims Processor, and the amount paid by the Plan on the claim. The term "Claim Payment Data" includes any document, material, or other work, whether tangible or electronic, that is derived from, is based on, or reflects any of the foregoing data fields or information contained therein. If the Claims Processor designates Claim Payment Data as a trade secret, the Claim Payment Data shall be treated as a trade secret as defined in G.S (3). (3) Claims Processor. One or more administrators, third-party administrators, or other parties contracting with the Plan to administer Plan benefits. (4) Comprehensive group health benefit plan. A comprehensive health benefit plan offered to an individual because of an employment, organizational, or other group affiliation. (5) Comprehensive health benefit plan. Health care coverage that consists of inpatient and outpatient hospital and medical benefits, as well as other outpatient medical services, prescription drugs, medical supplies, and equipment that are generally available in the health insurance market. (6) Covered service; benefit; allowable expense. Any medically necessary, reasonable, and customary items of service, including prescription drugs, and medical supplies included in the Plan. (7) Deductible. The dollar amount that must be incurred for certain covered services in a benefit period before benefits are payable by the Plan. (8) Dependent. An eligible Plan member other than the subscriber. (9) Dependent child. Subject to the eligibility requirements of subsections (a) and (b) of G.S , any of the following up to the first month following the dependent child's 26th birthday: a. A natural or legally adopted child or children of the employee, whether or not the child is living with the employee. NC General Statutes - Chapter 135 Article 3B 1

2 b. A foster child or children of the employee, whether or not the child is living with the employee. c. A child for which an employee is a court-appointed guardian. d. A stepchild of a member who is married to the stepchild's natural parent. e. Repealed by Session Laws , s. 3(a), effective July 1, (10) Employee or State employee. Any permanent full-time or permanent part-time regular employee (designated as half-time or more) of an employing unit. (11) Employing Unit. A North Carolina School System; Community College; State Department, Agency, or Institution; Administrative Office of the Courts; or Association or Examining Board whose employees are eligible for membership in a State-Supported Retirement System. An employing unit also shall mean (i) a charter school in accordance with Article 14A of Chapter 115C of the General Statutes whose board of directors elects to become a participating employer in the Plan under G.S or (ii) a local government unit that participates in the Plan under G.S or under any other law. Bona fide fire departments, rescue or emergency medical service squads, and National Guard units are deemed to be employing units for the purpose of providing benefits under this Article. (12) Firefighter. A member of the group "eligible firefighter" as defined in G.S (13) Health Benefits Representative or HBR. The employee designated by the employing unit to administer the Plan for the unit and its employees. The HBR is responsible for enrolling new employees and dependents in accordance with the eligibility requirements under this Article, reporting changes, explaining benefits, reconciling group statements, and remitting group fees. The State Retirement System is the Health Benefits Representative for retired State employees. (14) Plan or State Health Plan. The North Carolina State Health Plan for Teachers and State Employees. Depending on the context, the term may refer to the entity created in G.S [ ] or to the health benefit plans offered by the entity, in which case "Plan" includes all comprehensive health benefit plans offered under the Plan. (15) Plan member. A subscriber or dependent who is eligible and currently enrolled in the Plan and for whom a premium is paid. (16) Predecessor plan. The Hospital and Medical Benefits for the Teachers' and State Employees' Retirement System of the State of North Carolina and the North Carolina Teachers' and State Employees' Comprehensive Major Medical Plan. (17) Rescue squad worker. An "eligible rescue squad worker" as defined in G.S (18) Retired employee (retiree). Retired teachers, State employees, and members of the General Assembly who are receiving monthly retirement benefits from any retirement system supported in whole or in part by contributions of the State of North Carolina, so long as the retiree is enrolled. NC General Statutes - Chapter 135 Article 3B 2

3 (19) Subscriber. A Plan member who is not a dependent. ( , s. 3(e); , s. 3(a); , s. 1; , s. 1; , ss. 1.7(a), 1.10(c), 2.6(b), 2.10; , s. 3(a); , s. 102; , s. 19.3; , s. 1; , s. 1; , s. 5(a); , s. 7; , s. 1.) Undertaking. (a) The State of North Carolina undertakes to make available a State Health Plan (hereinafter called the "Plan") exclusively for the benefit of eligible employees, eligible retired employees, and certain of their eligible dependents, which will pay benefits in accordance with the terms of this Article. The Plan shall have all the powers and privileges of a corporation and shall be known as the State Health Plan for Teachers and State Employees. The State Treasurer, Executive Administrator, and Board of Trustees shall carry out their duties and responsibilities as fiduciaries for the Plan. The Plan shall administer one or more group health plans that are comprehensive in coverage. The State Treasurer may operate group plans as a preferred provider option, or health maintenance, point-of-service, or other organizational arrangement. (b) Payroll deduction shall be available for coverage under the Plan for subscribers able to meet the Plan's requirements for payroll deduction. ( , s. 3(c); , ss. 2(f), 5(h); , s. 1; , s. 2; , s. 18(b); , ss. 2.6(a), 2.10.) Right to amend. The General Assembly reserves the right to alter, amend, or repeal this Article. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, s. 62; , ss. 3(a), (u); , s. 2.6(k); , s. 5.) : Reserved for future codification purposes Health benefit trust funds created. (a) There are hereby established two health benefit trust funds, to be known as the Public Employee Health Benefit Fund and the Health Benefit Reserve Fund for the payment of hospital and medical benefits. As used in this section, the term "health benefit trust funds" refers to the fund type described under G.S. 143C-1-3(a)(10). All premiums, fees, charges, rebates, refunds or any other receipts including, but not limited to, earnings on investments, occurring or arising in connection with health benefits programs established by this Article, shall be deposited into the Public Employee Health Benefit Fund. Disbursements from the Fund shall include any and all amounts required to pay the benefits and administrative costs of such programs as may be determined by the Executive Administrator and Board of Trustees. Any unencumbered balance in excess of prepaid premiums or charges in the Public Employee Health Benefit Fund at the end of each fiscal year shall be used first, to provide an actuarially determined Health Benefit Reserve Fund for incurred but unpresented claims, second, to reduce the premiums required in providing the benefits of the health benefits programs, and third to improve the plan, as may be provided by the General Assembly. The balance in the Health Benefits Reserve Fund may be transferred from time to time to the Public Employee Health Benefit Fund to provide for any deficiency occurring therein. The Public Employee Health Benefit Fund and the Health Benefit Reserve Fund shall be deposited with the State Treasurer and invested as provided in G.S and NC General Statutes - Chapter 135 Article 3B 3

4 (b) Disbursement from the Public Employee Health Benefit Fund may be made by warrant drawn on the State Treasurer by the Executive Administrator, or the Executive Administrator and Board of Trustees may by contract authorize the Claims Processors to draw the warrant. (c) Repealed by Session Laws , s. 3(b), effective January 1, (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, ss. 43, 63; 1985 (Reg. Sess., 1986), c. 1020, s. 20; , s. 3; , s. 4(d); , s (a); , ss. 1(a), 2(a), (l); , s. 2.5(e); , s. 3(b).) : Reserved for future codification purposes Statements of public interest. (a) The State of North Carolina deems it to be in the public interest for North Carolina firefighters, rescue squad workers, and members of the National Guard, and certain of their dependents, who are not eligible for any other type of comprehensive group health insurance or other comprehensive group health benefits, and who have been without any form of group health insurance or other comprehensive group health benefit coverage for at least six consecutive months, to be given the opportunity to participate in the benefits provided by the State Health Plan for Teachers and State Employees. Coverage under the Plan shall be voluntary for eligible firefighters, rescue squad workers, and members of the National Guard who elect participation in the Plan for themselves and their eligible dependents. (b) The State of North Carolina deems it to be in the public interest for local government units to be allowed to join the State Health Plan for Teachers and State Employees and to participate in the Plan. ( , s. 3(c); , ss. 2(f), 5(h); , s. 1; , s. 2; , s. 18(b); , s. 2.6(a); , s. 2; , s. 1.) : Reserved for future codification purposes Confidentiality of information and medical records; provider contracts. (a) Any information described in this section that is in the possession of the State Health Plan for Teachers and State Employees or its Claims Processor under the Plan or the Predecessor Plan shall be confidential and shall be exempt from the provisions of Chapter 132 of the General Statutes or any other provision requiring information and records held by State agencies to be made public or accessible to the public. This section shall apply to all information concerning individuals, including the fact of coverage or noncoverage, whether or not a claim has been filed, medical information, whether or not a claim has been paid, and any other information or materials concerning a plan participant, including Claim Payment Data and any documents or other materials derived from the Claim Payment Data. This information may, however, be released to the State Auditor or to the Attorney General in furtherance of their statutory duties and responsibilities, or to such persons or organizations as may be designated and approved by the State Treasurer. Any information so released shall remain confidential as stated above and any party obtaining such information shall assume the same level of responsibility for maintaining such confidentiality as that of the State Health Plan for Teachers and State Employees. (b) The terms of a contract between the Plan and its third party administrator or between the Plan and its pharmacy benefit manager are a public record under Chapter 132 of the General NC General Statutes - Chapter 135 Article 3B 4

5 Statutes. No provision of law, however, shall be construed to prevent or restrict the release of any information in a Plan contract to the State Treasurer, the State Auditor, the Attorney General, the Director of the State Budget, the Plan's Board of Trustees, and the Plan's Executive Administrator solely and exclusively for their use in the furtherance of their duties and responsibilities. and after (1981, c. 355; 1981 (Reg. Sess., 1982), c. 1398, ss. 3, 4; 1983, c. 922, s ; 1985, c. 732, s. 38; 1985 (Reg. Sess., 1986), c. 1020, s. 20; , s. 4(h); , s A(c); , s (m); , s. 1(a), (c), (d); , s. 5(f); , s. 1; , s. 18(a); , ss. 1.9(a), 2.4(a), 2.10; , s. 15(r); , s. 2.) : Reserved for future codification purposes Committee on Actuarial Valuation of Retired Employees' Health Benefits. (a) There is established the Committee on Actuarial Valuation of Retired Employees' Health Benefits. The Committee shall be responsible for collecting data and reviewing assumptions for the sole purpose of conducting required actuarial valuations of State supported retired employees' health benefits under other post-employment benefit accounting standards set forth by the Governmental Accounting Standards Board of the Financial Accounting Foundation. (b) The Committee on Actuarial Valuation of Retired Employees' Health Benefits shall consist of five members serving ex officio, as follows: (1) The State Budget Officer, who shall serve as the Chair; (2) Repealed by Session Laws , s. 1, effective October 1, (3) The State Controller; (4) The State Treasurer; and (5) The Executive Administrator for the State Health Plan for Teachers and State Employees. (c) A majority of the members of the Committee then serving shall constitute a quorum. (d) Each member shall be entitled to one vote on the Committee. Three affirmative votes shall be necessary for a decision by the members at any meeting of the Committee. (e) The Committee shall keep in convenient form such data as is necessary for actuarial valuation of retired employees' health benefits under accounting standards set forth by the Governmental Accounting Standards Board of the Financial Accounting Foundation. The Department of State Treasurer, Retirement Systems Division, the State Health Plan for Teachers and State Employees, and any other State agency, department, or university institution, local public school agency, or local community college institution shall provide any necessary data upon request of the Committee for the purpose of conducting its responsibilities. (f) The Committee shall designate either the actuary under contract with the Department of State Treasurer, Retirement Systems Division, or the actuary under contract with the State Health Plan for Teachers and State Employees as the technical adviser to the Committee on matters regarding the actuarial valuation of retired employees' health benefits created by the provisions of this Chapter. The technical advisor shall perform such actuarial valuation and other duties as are required under this Chapter. (g) The Committee shall secure an annual calendar-year actuarial valuation of retired employees' health benefits under accounting standards set forth by the Governmental Accounting Standards Board of the Financial Accounting Foundation. NC General Statutes - Chapter 135 Article 3B 5

6 (h) The Committee shall keep a record of all of its proceedings which shall be open to public inspection. ( , s. 1; , s A(o); , s. 1(a), (c), (f); , ss. 2.4(b), 2.10; , s. 1.) : Reserved for future codification purposes : Reserved for future codification purposes Whistle-blower protections related to the State Health Plan. (a) Statement of Public Policy. It is the policy of this State that persons shall be encouraged to report verbally or in writing to the State Health Plan, Attorney General, or other appropriate authority evidence of activity related to the State Health Plan and involving the following: (1) A violation of State or federal law, rule, or regulation. (2) Fraud. (3) Misappropriation of State resources. (4) Gross mismanagement, a gross waste of monies, or gross abuse of authority. Further, it is the policy of this State that persons shall be free of intimidation or harassment when reporting matters of public concern related to the State Health Plan, including offering testimony to or testifying before appropriate legislative panels. (b) Protection From Retaliation. No employer shall sue, discharge, threaten, or otherwise discriminate against an employee regarding the employee's compensation, terms, conditions, location, or privileges of employment because the employee, or a person acting on behalf of the employee, reports or is about to report, verbally or in writing, any activity described in subsection (a) of this section, unless the employee knows or has reason to believe that the report is inaccurate. No other employee of an employer shall retaliate against another employee because the employee, or a person acting on behalf of the employee, reports or is about to report, verbally or in writing, any activity described in subsection (a) of this section. No person shall sue, terminate a contract, threaten, or otherwise discriminate against a reporting person regarding the reporting person's compensation or terms of contract because the reporting person, or a person acting on behalf of the reporting person, reports or is about to report, verbally or in writing, any activity described in subsection (a) of this section, unless the reporting person knows or has reason to believe that the report is inaccurate. (c) Relief for Violation. Any person injured by a violation of subsection (b) of this section may maintain an action in superior court for damages, an injunction, or other remedies provided in this section against the person who committed the violation within one year after the occurrence of the alleged violation of this Article. (d) Remedies. A court, in rendering a judgment in an action brought pursuant to this section, may order an injunction, damages, reinstatement of the employee, the payment of back wages or payments owed under a contract, full reinstatement of fringe benefits and seniority rights, costs, reasonable attorneys' fees, or any combination of these. If an application for a permanent injunction is granted, the person maintaining the action shall be awarded costs and reasonable attorneys' fees. If in an action for damages the court finds that the person maintaining the action was injured by a willful violation of subsection (b) of this section, the court shall award as damages three times the amount of actual damages plus costs and reasonable attorneys' fees against the individual or individuals found to be in violation of subsection (b) of this section. NC General Statutes - Chapter 135 Article 3B 6

7 (e) Unrelated Unfavorable Action. It shall not be a violation of this Article for a person to discharge or take any other unfavorable action with respect to an employee who has engaged in protected activity as set forth under this Article if the person proves by the greater weight of the evidence that it would have taken the same unfavorable action in the absence of the protected activity of the employee. ( , s. 3.) : Reserved for future codification purposes : Reserved for future codification purposes : Reserved for future codification purposes : Reserved for future codification purposes. Part 2. Administrative Structure Board of Trustees established. (a) There is established the Board of Trustees of the State Health Plan for Teachers and State Employees. (b) The Board of Trustees of the State Health Plan for Teachers and State Employees shall consist of 10 members. (c) The State Treasurer shall be an ex officio member of the Board and shall serve as its Chair, but shall only vote in order to break a tie vote. (d) The Director of the Office of State Budget and Management shall be an ex officio nonvoting member of the Board. (e) Two members shall be appointed by the Governor. Terms shall be for two years. Vacancies shall be filled by the Governor. (f) Two members shall be appointed by the State Treasurer. Terms shall be for two years. Vacancies shall be filled by the State Treasurer. (g) Two members shall be appointed by the General Assembly upon the recommendation of the Speaker of the House of Representatives in accordance with G.S Terms shall be for two years. Vacancies shall be filled in accordance with G.S (h) Two members shall be appointed by the General Assembly upon the recommendation of the President Pro Tempore of the Senate in accordance with G.S Terms shall be for two years. Vacancies shall be filled in accordance with G.S (i) In making appointments, the appointing authorities shall ensure that one of the appointees under subsection (e) of this section, one of the appointees under subsection (f) of this section, and one of the appointees under subsection (g) of this section, and one of the appointees under subsection (h) of this section are one of the following: (1) An employee of a State department, agency, or institution; (2) A teacher employed by a North Carolina public school system; (3) A retired employee of a State department, agency, or institution; or (4) A retired teacher from a North Carolina public school system. In making appointments to the Board under this section, each appointing authority shall consult with all other appointing authorities prior to making its own appointments to ensure that the Board includes members of each of the groups listed in subdivisions (1) through (4) of this subsection. NC General Statutes - Chapter 135 Article 3B 7

8 (j) In making appointments, the appointing authorities shall appoint individuals from the following areas of expertise: (1) Actuarial science. (2) Health economics. (3) Health benefits and administration. (4) Health law and policy. In making appointments to the Board under this section, each appointing authority shall consult with all other appointing authorities prior to making its own appointments to ensure that each of the areas of expertise listed in subdivisions (1) through (4) of this subsection is represented by at least one member of the Board. (k) Each appointing authority may remove any member appointed by that appointing authority. (l) The members of the Board of Trustees shall receive one hundred dollars ($100.00) per day, except employees eligible to enroll in the Plan, whenever the full Board of Trustees holds a public session, and travel allowances under G.S when traveling to and from meetings of the Board of Trustees or hearings under G.S , but shall not receive any subsistence allowance or per diem under G.S , except when holding a meeting or hearing where this section does not provide for payment of one hundred dollars ($100.00) per day. (m) No member of the Board of Trustees may serve more than three consecutive two-year terms. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1983, c. 922, s. 1; 1985, c. 732, ss. 2-5, 8, 11, 42, 59, 60; 1985 (Reg. Sess., 1986), c. 1020, s. 1; 1987, c. 857, s. 2; 1995, c. 490, s. 56; , s (a); , s A(b); , ss. 1(a), 2(a), (e); , ss. 2.5(a), 2.10; , s. 6(a).) Board officers, quorum, meetings. (a) Besides the Chair, the Board of Trustees shall elect from its own membership such officers as it sees fit. (b) A majority of the voting members of the Board of Trustees in office shall constitute a quorum. Decisions of the Board of Trustees shall be made by a majority vote of the Trustees present, except as otherwise provided in this Article. (c) The Board shall meet at least quarterly. Meetings may also be called by the Chair, or at the written request of three members. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1987, c. 857, s. 3; , ss. 1(a), 2(a), (f); , s. 5(c); , ss. 2.5(b), 2.10.) Board powers and duties. The Board of Trustees shall have the following powers and duties: (1) Approve benefit programs, as provided in G.S (a)(2). (2) Approve premium rates, co-pays, deductibles, and coinsurance percentages and maximums for the Plan, as provided in G.S (a)(2). (2a) Approve the benefit program, premium rates, co-pays, deductibles, and coinsurance percentages and maximums for the coverage offered under G.S (e). (3) Oversee administrative reviews and appeals, as provided in G.S (4) Approve large contracts, as provided in G.S (a). (5) Consult with and advise the State Treasurer as required by this Article and as requested by the State Treasurer. NC General Statutes - Chapter 135 Article 3B 8

9 (6) Develop and maintain a strategic plan for the Plan. ( , s. 2.10; , s. 4(a); , s (b).) Executive Administrator. (a) The Plan shall have an Executive Administrator and a Deputy Executive Administrator. The Executive Administrator and the Deputy Executive Administrator positions are exempt from the provisions of Chapter 126 of the General Statutes as provided in G.S (c1). (b) The Executive Administrator shall be appointed by the State Treasurer. The term of employment and salary of the Executive Administrator shall be set by the State Treasurer after consultation with the Board of Trustees. The Executive Administrator may be removed from office by the State Treasurer after consultation with the Board of Trustees, and any vacancy in the office of Executive Administrator may be filled by the State Treasurer. (c) The Executive Administrator shall appoint the Deputy Executive Administrator and may employ such clerical and professional staff, and such other assistance as may be necessary to assist the Executive Administrator, the Board of Trustees, and the State Treasurer in carrying out their duties and responsibilities under this Article. The Executive Administrator may designate managerial, professional, or policy-making positions as exempt from the North Carolina Human Resources Act. The Executive Administrator may also negotiate, renegotiate and execute contracts with third parties in the performance of the Executive Administrator's duties and responsibilities under this Article; provided any contract negotiations, renegotiations and execution with a Claims Processor, with an optional alternative comprehensive health benefit plan, or program thereunder, authorized under G.S , with a preferred provider of institutional or professional hospital and medical care, or with a pharmacy benefit manager shall be done only after consultation with the State Treasurer. (d) The Executive Administrator shall quarterly make reports and recommendations on the Plan to the President Pro Tempore of the Senate and the Speaker of the House of Representatives. (1985, c. 732, s. 10; 1985 (Reg. Sess., 1986), c. 1020, s. 20; 1987, c. 857, s. 5; 1991, c. 427, s. 2; , s. 2; , s. 6; , s (a); , ss (c), 29.34(a); , s A(l); , ss. 1(a), 2(a), (h), 2.2; , ss. 2.1(a), 2.5(c), 2.10; , s. 9.1(c).) Administrative review. (a) If, after exhaustion of internal appeal handling as outlined in the contract with the Claims Processor any person is aggrieved, the Claims Processor shall bring the matter to the attention of the Executive Administrator and Board of Trustees, which shall promptly decide whether the subject matter of the appeal is a determination subject to external review under Part 4 of Article 50 of Chapter 58 of the General Statutes. The Executive Administrator and Board of Trustees shall inform the aggrieved person and the aggrieved person's provider of the decision and shall provide the aggrieved person notice of the aggrieved person's right to appeal that decision as provided in this subsection. If the Executive Administrator and Board of Trustees decide that the subject matter of the appeal is not a determination subject to external review, then the Executive Administrator and Board of Trustees may make a binding decision on the matter in accordance with procedures established by the Executive Administrator and Board of Trustees. The Executive Administrator and Board of Trustees shall provide a written summary of the NC General Statutes - Chapter 135 Article 3B 9

10 decisions made pursuant to this section to all employing units, all health benefit representatives, all relevant health care providers affected by a decision, and to any other parties requesting a written summary and approved by the Executive Administrator and Board of Trustees to receive a summary immediately following the issuance of a decision. A decision by the Executive Administrator and Board of Trustees that a matter raised on internal appeal is a determination subject to external review as provided in subsection (b) of this section may be contested by the aggrieved person under Chapter 150B of the General Statutes. The person contesting the decision may proceed with external review pending a decision in the contested case under Chapter 150B of the General Statutes. (b) The State Treasurer, in consultation with the Board of Trustees, shall adopt and implement utilization review and internal grievance procedures that are substantially equivalent to those required under G.S and G.S External review of determinations shall be conducted in accordance with Part 4 of Article 50 of Chapter 58 of the General Statutes. As used in this section, "determination" is a decision by the State Treasurer, or the Plan's designated utilization review organization administrated by or under contract with the Plan that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon information provided, does not meet the Plan's requirements for medical necessity, appropriateness, health care setting, or level of care or effectiveness, and the requested service is therefore denied, reduced, or terminated. (c) Repealed by Session Laws , s. 49, effective January 1, 2012, and applicable to contested cases commenced on or after that date. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, s. 53; 1985 (Reg. Sess., 1986), c. 1020, s. 20; 1991, c. 427, s. 6; , s. 5(e); , ss. 1(a), 2(a), (n); , ss. 2.5(g), 2.10; , s. 49.) Rules. The State Treasurer, in consultation with the Board of Trustees, may adopt rules to implement this Article. The State Treasurer shall provide to all employing units, all health benefit representatives, all relevant health care providers affected by a rule, and to any other persons requesting a written description and approved by the State Treasurer written notice and an opportunity to comment not later than 30 days prior to adopting, amending, or rescinding a rule, unless immediate adoption of the rule without notice is necessary in order to fully effectuate the purpose of the rule. Rules of the Board of Trustees shall remain in effect until amended or repealed by the State Treasurer. The State Treasurer shall provide a written description of the rules adopted under this section to all employing units, all health benefit representatives, all relevant health care providers affected by a rule, and to any other persons requesting a written description and approved by the State Treasurer on a timely basis. Rules adopted by the State Treasurer to implement this Article are not subject to Article 2A of Chapter 150B of the General Statutes. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, s. 54; 1991, c. 427, s. 7; , s. 3; , s. 5; , s. 4(f); , s. 1(r); , ss. 1(a), 2(a), (o); , ss. 2.5(h), 2.10.) : Reserved for future codification purposes Reports to the General Assembly; General Assembly access to information. In addition to the reports required by G.S (d), the State Treasurer, the Executive Administrator, and Board of Trustees shall report to the General Assembly at such times and in NC General Statutes - Chapter 135 Article 3B 10

11 such forms as shall be designated by the President Pro Tempore of the Senate and the Speaker of the House of Representatives. Employees of the Legislative Services Commission designated by the Legislative Services Officer (i) shall have access to all records related to the Plan of the State Treasurer, the Board of Trustees, the Executive Administrator, the Claims Processor, and the Plan and (ii) shall be entitled to attend all meetings, including executive sessions, of the Board of Trustees. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985, c. 732, ss. 55, 55.1; 1985 (Reg. Sess., 1986), c. 1020, s. 7; , ss. 1(a), (c), 2(c); , ss. 2.4(d), 2.10; , s. 30.) Auditing of the Plan. The State Health Plan for Teachers and State Employees and the Claims Processor shall be subject to the oversight of the State Auditor pursuant to Article 5A of Chapter 147 of the General Statutes. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1983, c. 913, s. 24; 1985, c. 732, s. 46; 1985 (Reg. Sess., 1986), c. 1020, p. 20; , s A(o); , s. 12; , ss. 1(a), (c), 2(g); , ss. 2.4(c), 2.10.) Part 3. Plan Operation Powers and duties of the State Treasurer. (a) The State Treasurer shall have the following powers and duties: (1) Administer and operate the State Health Plan for Teachers and State Employees in accordance with G.S and the provisions of this Article. (2) Set benefits, premium rates, co-pays, deductibles, and coinsurance percentages and maximums, subject to approval by the Board of Trustees. In setting premium rates, the State Treasurer may set a partially contributory rate of zero dollars, subject to approval by the Board of Trustees. (3) Set the allowable charges for medical and prescription drug benefits, as necessary. (4) Design and implement coordination of benefits policies. (5) May offer wellness incentives. (6) Set administrative and medical policies that are not in direct conflict with this Article. (7) Adopt and implement, in consultation with the Board of Trustees, utilization review and internal grievance procedures that are substantially equivalent to those required under G.S and G.S External review of determinations shall be conducted in accordance with Part 4 of Article 50 of Chapter 58 of the General Statutes. (8) Implement and administer pharmacy and medical utilization management programs and programs to detect and address utilization abuse of benefits. (9) Establish and operate fraud detection and audit programs. (10) Expend funds for any independent audit. (11) Establish procedures to require prior medical approval and implement the procedures after consultation with the Board of Trustees. (12) Prepare and submit to the Governor and the General Assembly cost estimates for the Plan, including those required by Article 15 of Chapter 120 of the General Statutes. NC General Statutes - Chapter 135 Article 3B 11

12 (13) Disclose to the Governor and the General Assembly changes or additions to the health benefits programs and health care cost containment programs offered under the Plan, together with statements of financial and actuarial effects as required by Article 15 of Chapter 120 of the General Statutes. (14) Secure and maintain tax qualification of the Plan under any applicable provisions of the Internal Revenue Code. (15), (16) Repealed by Session Laws , s. 3(c), effective January 1, (17) Optionally offer Medicare-related options under G.S (b) The State Treasurer may delegate his or her powers and duties under this section to the Executive Administrator, the Board of Trustees, and employees of the Plan. In delegating powers or duties, however, the State Treasurer maintains the responsibility for the performance of those powers or duties. ( , s. 2.10; , s. 3(c), 4(b).) : Reserved for future codification purposes Contracts to provide benefits. (a) The Plan benefits shall be provided under contracts between the Plan and the claims processors selected by the Plan. The contracts necessarily will conform to applicable State law. (b) Unless otherwise directed by the Plan, each Claims Processor shall provide the Plan with a Claims Data Feed, which includes all Claim Payment Data, at a frequency agreed to by the Plan and the Claims Processor. The frequency shall be no less than monthly. The Claims Processor is not required to disclose Claim Payment Data that reflects rates negotiated with or agreed to by a noncontracted third party but, upon request, shall provide to the Plan sufficient documentation to support the payment of claims for which Claim Payment Data is withheld on such basis. (c) Any provision of any contract between a Claims Processor and a health care provider, subcontractor, or third party that would prevent or prohibit the Claims Processor from disclosing Claim Payment Data to the Plan, in accordance with this section, shall be void and unenforceable, but only to the extent the provision prevents and prohibits disclosure to the Plan. (d) The Plan may use and disclose Claim Payment Data solely for the purpose of administering and operating the State Health Plan for Teachers and State Employees in accordance with G.S and the provisions of this Article. The Plan shall not make any use or disclosure of Claim Payment Data that would compromise the proprietary nature of the data or, as applicable, its status as a trade secret, or otherwise misappropriate the data. (e) The Plan may not use a provider's Claim Payment Data to negotiate rates, fee schedules, or other master charges with that provider or any other provider. (f) The Plan may disclose Claim Payment Data to a third party to use on the Plan's behalf as agreed upon between the Plan and the Claims Processor. The Plan must obtain the agreement of the Claims Processor for each third party to whom the Plan seeks to disclose Claim Payment Data and for each use the third party will make of the data. The Plan may not disclose Claim Payment Data to any third party without first entering into a contract with the third party that contains restrictions on the use and disclosure of the Claim Payment Data by the third party that are at least as restrictive as the provisions of this section. (g) A Claims Processor who discloses Claim Payment Data in accordance with this section shall not incur any civil liability and shall not be subject to equitable relief in connection NC General Statutes - Chapter 135 Article 3B 12

13 for the disclosure. ( , s. 3(c); , ss. 2(f), 5(h); , s. 1; , s. 2; , s. 18(b); , ss. 2.6(a), 2.10; , s. 3.) Contracting provisions; large contract review by Board of Trustees and Attorney General, auditing, no cost plus contracts. (a) The Board of Trustees must approve all Plan contracts in excess of five hundred thousand dollars ($500,000), including contracts with an initial cost of less than five hundred thousand dollars ($500,000), but that may exceed five hundred thousand dollars ($500,000) during the term of the contract. (b) The Plan shall: (i) submit all proposed contracts for supplies, materials, printing, equipment, and contractual services that exceed one million dollars ($1,000,000) authorized by this Article to the Attorney General or the Attorney General's designee for review as provided in G.S ; and (ii) include in all proposed contracts to be awarded by the Plan under this section a standard clause which provides that the State Auditor and internal auditors of the Plan may audit the records of the contractor during and after the term of the contract to verify accounts and data affecting fees and performance. The Plan shall not award a cost plus percentage of cost agreement or contract for any purpose. ( , s. 3(c); , ss. 2(f), 5(h); , s. 1; , s. 2; , s. 18(b); , ss. 2.6(a), 2.10; , s. 15(s).) Contracts not subject to Article 3 of Chapter 143 of the General Statutes. The design, adoption, and implementation of the preferred provider contracts, networks, and optional alternative comprehensive health benefit plans, and programs available under the optional alternative plans, as authorized under G.S , are not subject to the requirements of Article 3 of Chapter 143 of the General Statutes, but are subject to the requirements of G.S ( , s ) Contract disputes not contested case under the Administrative Procedure Act, Chapter 150B of the General Statutes. A dispute involving the performance, terms, or conditions of a contract between the Plan and an entity under contract with the Plan is not a contested case under Article 3 of Chapter 150B of the General Statutes. ( , s. 2; , ss. 1(a), (c), 2(d); , s. 2.4(e).) : Reserved for future codification purposes Liability of third person; right of subrogation; right of first recovery. (a) The Plan shall have the right of subrogation upon all of the Plan member's right to recover from a liable third party for payment made under the Plan, for all medical expenses, including provider, hospital, surgical, or prescription drug expenses, to the extent those payments are related to an injury caused by a liable third party. The Plan member shall do nothing to prejudice these rights. The Plan has the right to first recovery on any amounts so recovered, whether by the Plan or the Plan member, and whether recovered by litigation, arbitration, mediation, settlement, or otherwise. Notwithstanding any other provision of law to the contrary, the recovery limitation set forth in G.S. 28A-18-2 shall not apply to the Plan's right of subrogation of Plan members. NC General Statutes - Chapter 135 Article 3B 13

14 (b) If the Plan is precluded from exercising its right of subrogation, it may exercise its rights of recovery against any third party who was overpaid. If the Plan recovers damages from a liable third party in excess of the claims paid, any excess will be paid to the member, less a proportionate share of the costs of collection. (c) In the event a Plan member recovers any amounts from a liable third party to which the Plan is entitled under this section, the Plan may recover the amounts directly from the Plan member. The Plan has a lien, for not more than the value of claims paid related to the liability of the third party, on any damages subsequently recovered against the liable third party. If the Plan member fails to pursue the remedy against a liable third party, the Plan is subrogated to the rights of the Plan member and is entitled to enforce liability in the Plan's own name or in the name of the Plan member for the amount paid by the Plan. (d) In no event shall the Plan's lien exceed fifty percent (50%) of the total damages recovered by the Plan member, exclusive of the Plan member's reasonable costs of collection as determined by the Plan in the Plan's sole discretion. The decision by the Plan as to the reasonable cost of collection is conclusive and is not a "final agency decision" for purposes of a contested case under Chapter 150B of the General Statutes. Notice of the Plan's lien or right to recovery shall be presumed when a Plan member is represented by an attorney, and the attorney shall disburse proceeds pursuant to this section. ( , s ; , s. 66(a); , ss. 1(a), 3(a), (t); , ss. 2.6(j), 2.10.) Persons eligible for Medicare; optional participation in other Medicare products. (a) Benefits payable for covered expenses under this Plan will be reduced by any benefits payable for the same covered expenses under Medicare, so that Medicare will be the primary carrier except where compliance with federal law specifies otherwise. (b) For those participants eligible for Medicare, the Plan will be administered on a "carve out" basis. The provisions of the Plan are applied to the charges not paid by Medicare (Parts A & B). In other words, those charges not paid by Medicare would be subject to the deductible and coinsurance of the Plan just as if the charges not paid by Medicare were the total bill. (c) For those individuals eligible for Part A (at no cost to them), benefits under this program will be reduced by the amounts to which the covered individuals would be entitled to under Parts A and B of Medicare, even if they choose not to enroll for Part B. (d) Notwithstanding the foregoing provisions of this section or any other provisions of the Plan, the State Treasurer may enter into negotiations with the Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, in order to secure a more favorable coordination of the Plan's benefits with those provided by Medicare, including but not limited to, measures by which the Plan would provide Medicare benefits for all of its Medicare-eligible members in return for adequate payments from the federal government in providing such benefits. Should such negotiations result in an agreement favorable to the Plan and its Medicare-eligible members, the State Treasurer may, after consultation with the Board of Trustees, implement such an agreement which shall supersede all other provisions of the Plan to the contrary related to its payment of claims for Medicare-eligible members. (e) Notwithstanding subsections (a), (b), and (c) of this section, the State Treasurer may contract for coverage in lieu of current Plan medical and prescription drug benefits for Medicare retirees or to supplement Medicare benefits and may, after consultation with the Board of Trustees, implement such an agreement, which shall supersede all other provisions of the Plan to NC General Statutes - Chapter 135 Article 3B 14

15 the contrary related to its payment of claims for Medicare-eligible members. (1981 (Reg. Sess., 1982), c. 1398, s. 6; 1985 (Reg. Sess., 1986), c. 1020, s. 18; 1987, c. 857, s. 21; 1989, c. 752, s. 22(o); , ss. 1(a), 3(a), (o); , ss. 2.6(g), 2.10.) : Reserved for future codification purposes. Part 4. Eligibility and Enrollment Categories of eligibility. (a) Noncontributory Coverage. The following persons are eligible for coverage under the Plan, on a noncontributory basis, subject to the provisions of G.S : (1) Retired teachers, State employees, members of the General Assembly, and retired State law enforcement officers who retired under the Law Enforcement Officers' Retirement System prior to January 1, Except as otherwise provided in this subdivision, on and after January 1, 1988, a retiring employee or retiree must have completed at least five years of contributory retirement service with an employing unit prior to retirement from any State-supported retirement system in order to be eligible for group benefits under this Part as a retired employee or retiree. For employees first hired on and after October 1, 2006, and members of the General Assembly first taking office on and after February 1, 2007, future coverage as retired employees and retired members of the General Assembly is subject to a requirement that the future retiree have 20 or more years of retirement service credit in order to be covered by the provisions of this subdivision. (2) Surviving spouses of: a. Deceased retired employees, provided the death of the former plan member occurred prior to October 1, 1986; and b. Deceased teachers, State employees, and members of the General Assembly who are receiving a survivor's alternate benefit under any of the State-supported retirement programs, provided the death of the former plan member occurred prior to October 1, (b) Partially Contributory Coverage. The following persons are eligible for coverage under the Plan, on a partially contributory basis, subject to the provisions of G.S : (1) All permanent full-time employees of an employing unit who meet either of the following conditions: a. Paid from general or special State funds. b. Paid from non-state funds and in a group for which his or her employing unit has agreed to provide coverage. Employees of State agencies, departments, institutions, boards, and commissions not otherwise covered by the Plan who are employed in permanent job positions on a recurring basis and who work 30 or more hours per week for nine or more months per calendar year are covered by the provisions of this subdivision. (1a) All retirees who (i) are employed by an employing unit that elects to be covered by this subdivision, (ii) do not qualify for coverage under subdivision (1) of this subsection, and (iii) are determined to be "full-time" by their employing unit in accordance with section 4980H of the Internal Revenue NC General Statutes - Chapter 135 Article 3B 15